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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> eeob -;1 'S& l <br /> OWNER/OPERATOR <br /> MINo2 44o1-5 1l.1— c— CHECK IfBILLING ADDRESS <br /> � <br /> FACILITY NAME <br /> SITE ADDRESS .� p(E JR-tr S a'--0*9 CZ47-- <br /> Stre¢t Number Direction Street Nae city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 6507PAC tFtG f1"6 , *E 134} F-O.9on 6g6Z7 <br /> Street Number Street Name <br /> CITY r7+�-� STATE ZIP g t u Q <br /> g 41S207 / <br /> PHONE#t E'' APN# LAND USE APPLICATION# <br /> 1 1 613-030 07 '• 8' PA - f:Ca> L6tf <br /> PHONE Irl E>ct' BOS DISTRICT LOCATION CODE <br /> ( 1 ool 11 99 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mt I&V <br /> -FD1 CHECK If BILLING ADDRESS <br /> PHONE# E". <br /> BUSINESS NAME DI LA-0— e IAA.u+l.P (-7o-() 33'4- 66 (71 <br /> HOME or MAILING ADDRESSFAX# <br /> P- O. 7Uox 21Zo (749) 334- 6`7-; <br /> CITY Lc59; STATE C. ZIP c) S Z4 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT a EO L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY Proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environment sessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and a �(Lj5 <br /> provided to me or my representative. �� <br /> TYPE OF SERVICE REQUESTED: Jq <br /> COMMENTS: ` /I /1 (�O .n i �. ` SgNJOgQ 18 <br /> 4J V/ <br /> MfALNM p0 1A,MUNIY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SE 'ACE CODE: ^t PIE: 1 <br /> Fee Amount: ' Amount Pai Payment Date <br /> Payment Type Invoice# Check# �.5 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />